Overnight removal of urinary indwelling catheter following vaginal prolapse surgery (OVERACT).

OBJECTIVE: Pelvic organ prolapse is a common condition in women. Adequate timing of urinary catheter removal after vaginal prolapse surgery is essential to reduce post-operative morbidity. We compared midnight removal of the indwelling urinary catheter to removal next morning. METHODS: We performed a retrospective cohort study among 266 women undergoing vaginal prolapse surgery, of whom 132 women had urinary catheter removal at midnight and 134 women morning after surgery. We compared the occurrence of urinary retention, time till first micturition, need for clean intermittent catherization and duration of hospital admission. Also, we assessed risk factors for the occurrence of retention. RESULTS: Retention occurred less after midnight removal of the urinary catheter, compared to removal next morning (6.1 % versus 23.9 %, p < 0.001). Furthermore, the time till catheter removal and discharge from hospital were shorter and the need for clean intermittent catheterization during hospital admission was lower after midnight compared to next morning removal of the urinary catheter. We identified anterior colporrhaphy as a risk factor for retention. CONCLUSION: Our results suggest that early removal of the indwelling urinary catheter after vaginal prolapse surgery seems save with respect to urinary retention and leads to earlier mobilization and shorter hospital admission.

Cost-Effectiveness of perioperative Vaginally Administered estrogen in postmenopausal women undergoing prolapse surgery (EVA trial): study protocol for a multicenter double-blind randomized placebo-controlled trial.

BACKGROUND: Surgery for pelvic organ prolapse (POP) is associated with high recurrence rates. The costs associated with the treatment of recurrent POP are huge, and the burden from women who encounter recurrent POP, negatively impacts their quality of life. Estrogen therapy might improve surgical outcome for POP due to its potential beneficial effects. It is thought that vaginal estrogen therapy improves healing and long-term maintenance of connective tissue integrity. Hence, this study aims to evaluate the cost-effectiveness of perioperative vaginal estrogen therapy in postmenopausal women undergoing POP surgery. METHODS: The EVA trial is a multi-center double-blind randomized placebo-controlled trial conducted in the Netherlands comparing the effectiveness and costs-effectiveness of vaginal estrogen therapy. This will be studied in 300 postmenopausal women undergoing primary POP surgery, with a POP-Q stage of ≥ 2. After randomization, participants administer vaginal estrogen cream or placebo cream from 4 to 6 weeks preoperative until 12 months postoperative. The primary outcome is subjective improvement of POP symptoms at 1 year follow-up, measured with the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes are POP-Q anatomy in all compartments, re-interventions, surgery related complications, general and disease specific quality of life, sexual function, signs and complaints of vaginal atrophy, vaginal pH, adverse events, costs, and adherence to treatment. Follow up is scheduled at 6 weeks, 6 months and 12 months postoperative. Data will be collected using validated questionnaires and out-patient visits including gynecological examination performed by an independent gynecologist. DISCUSSION: This study investigates whether perioperative vaginal estrogen will be cost-effective in the surgical treatment of POP in postmenopausal women. It is hypothesized that estrogen therapy will show a reduction in recurrent POP symptoms and a reduction in reoperations for POP, with subsequent improved quality of life among women and cost savings. Trial registrationNetherlands Trial Registry: NL6853; registered 19-02-2018, https://www.trialregister.nl/trial/6853 . EudraCT: 2017-003144-21; registered: 24-07-2017.

Postpartum sexual function; the importance of the levator ani muscle.

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle function plays an important role in female sexual functioning. Smaller genital hiatal dimensions have been associated with sexual dysfunction, mainly dyspareunia. On the other hand, trauma of the levator ani muscle sustained during childbirth is associated with increased genital hiatus, which potentially can affect sexual functioning by causing vaginal laxity. This study aims to determine the association between levator hiatal dimensions and female sexual dysfunction after first vaginal delivery. METHODS: This is a secondary analysis of a prospective observational study. Two hundred four women who had a first, spontaneous vaginal delivery at term between 2012 and 2015 were recruited at a minimum of 6 months postpartum. Thirteen pregnant women were excluded. We analyzed the association of total PISQ-12 score, as well as individual sexual complaints (desire, arousal, orgasm and dyspareunia), with levator hiatal dimensions at rest, with maximum Valsalva and during pelvic floor muscle contraction as measured by 4D transperineal ultrasound. Statistical analysis was performed using linear regression analysis and Mann-Whitney U test. RESULTS: One hundred ninety-one women were evaluated at a median of 11 months postpartum. There was no significant association between total PISQ-12 score and levator hiatal dimensions. Looking at individual sexual complaints, women with dyspareunia had significantly smaller levator hiatal area and anterior-posterior diameter on maximum Valsalva. By using multivariate logistic regression analysis however we found dyspareunia was not independently associated with levator hiatal dimensions. CONCLUSIONS: After first vaginal delivery sexual dysfunction is not associated with levator hiatal dimensions as measured by 4D transperineal ultrasound.

Three-dimensional bladder ultrasonography with the BladderScan® overestimates post void residual one week after delivery.

OBJECTIVE: Postpartum urinary retention is a frequent complication after childbirth. It is usually a temporary condition. However, unrecognised urinary retention can lead to considerable morbidity due to bladder over distention, detrusor atony and long term voiding dysfunction. In our clinic we noticed an overestimation of post void residual measured with the BladderScan® in comparison with catheterization in women one week after delivery. STUDY DESIGN: We included 25 women in this prospective pilot study. These women had a urinary retention over 1000 ml within 4-5 h postpartum. Conform our local protocol, an indwelling catheter was inserted for one week. After removal of the indwelling catheter, a micturition trial was conducted. The post void residual was first measured with BladderScan® (BVI 3000), directly followed by clean intermittent catheterization which is the golden standard at this moment. RESULTS: There was a significant mean difference in post void residual measurements with the BladderScan® and catheterization of 312 ml (95% CI 220-404 ml) (p < 0.001). According to our post void residual definition of 200 ml, the sensitivity and specificity of the BladderScan® was respectively 100% and 17.6%. The positive predictive value was 36%. CONCLUSION: The BladderScan® (BVI 3000) is a non-reliable instrument to measure post void residual one week postpartum. For now clean intermittent catherization remains the golden standard.

Association of levator injury and urogynecological complaints in women after their first vaginal birth with and without mediolateral episiotomy.

BACKGROUND: Pelvic organ prolapse is a common health problem in women and has a negative influence on quality of life. A major cause of pelvic organ prolapse is levator injury. OBJECTIVE: The objective of the study was to evaluate the association of mediolateral episiotomy with levator injury (levator avulsion, ballooning, or combined) and urogynecological complaints. STUDY DESIGN: A prospective observational cohort study was performed in 204 primiparous women with a spontaneous vaginal delivery without anal sphincter tear in a general hospital between 2012 and 2015. One hundred three of these women had had a mediolateral episiotomy. Validated urogynecological questionnaires and transperineal 3-dimensional/4-dimensional ultrasound were completed after delivery. Outcome measures were levator avulsion, ballooning (hiatal area of more than 25 cm2), and urogynecological questionnaire scores. Statistical analysis was performed using univariate and multiple logistic regression analysis. RESULTS: The median time at investigation after vaginal delivery was 13 months (range 6-33). Levator injury (avulsion, ballooning, or combined) was identified in 35 of the 103 women who had undergone mediolateral episiotomy (40.0%) and 33 of the 101 women without episiotomy (32.7%) (P = .69). No differences were found in the incidence of levator avulsion 27 (26.7%) vs 23 (22.8%) (P = .53) or in levator ballooning (20 [19.4%] vs 23 [22.8%] (P = .58) between both groups. There was an association between longer duration of the second stage of labor and the incidence of levator avulsion (odds ratio, 1.24 [95% confidence interval, 1.01-1.52]). Nonocciput anterior fetal position increased the risk of levator ballooning and levator injury (odds ratio, 10.19 [95% confidence interval, 1.89-54.91] and odds ratio, 12.16 [95% confidence interval, 1.41-104.38], respectively). No differences in urogynecological complaints were found. CONCLUSION: Mediolateral episiotomy is not associated with the occurrence of levator injury or urogynecological complaints in women with a spontaneous vaginal delivery who did not obtain an anal sphincter injury. Levator injury was associated with a prolonged second stage of labor and a nonocciput anterior fetal position.

A de novo GLI3 mutation in a patient with acrocallosal syndrome.

Acrocallosal syndrome is characterized by postaxial polydactyly, macrocephaly, agenesis of the corpus callosum, and severe developmental delay. In a few patients with this disorder, a mutation in the KIF7 gene has been reported, which was associated with impaired GLI3 processing and dysregulaton of GLI3 transcription factors. A single patient with acrocallosal syndrome and a de novo p.Ala934Pro mutation in GLI3 has been reported, whereas diverse and numerous GLI3 mutations have also been described in syndromes with overlapping clinical manifestations, including Greig cephalopolysyndactyly syndrome, Pallister-Hall syndrome, trigonocephaly with craniosynostosis and polydactyly, oral-facial-digital syndrome, and non-syndromic polydactyly. Here, we describe a second patient with acrocallosal syndrome, who has a de novo, novel c.2786T>C mutation in GLI3, which predicts p.Leu929Pro. This mutation is in the same domain as the mutation in the previously reported patient. These data confirm that mutations in GLI3 are a cause of the acrocallosal phenotype.

[A full-term fetal death]. / Een aterme overleden foetus.

A 31-year-old woman came to the clinic in the 37th week of her pregnancy because she did not feel movements of the fetus anymore. It appeared intrauterine death had occurred because of strangulation of the umbilical cord by an amniotic band, which led to cardiocirculatory insufficiency of the fetus.

Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is a biomarker of cardiac filling pressures in pre-eclampsia.

OBJECTIVE: To evaluate if amino-terminal pro-brain natriuretic peptide (NT-proBNP) plasma levels reflect intracardiac filling pressures in pre-eclamptic patients. STUDY DESIGN: In a cross-sectional study we investigated 22 untreated critically ill pre-eclamptic women between 22 and 34 weeks gestation. All patients underwent intra-arterial blood pressure and central hemodynamic measurements and NT-proBNP was determined in stored plasma. Baseline characteristics, plasma NT-proBNP concentrations and relevant laboratory variables were investigated for correlations with hemodynamic values using Spearman's rank correlation test. RESULTS: No significant correlations were demonstrated between NT-proBNP concentrations and variables associated with the severity of the pre-eclampsia. We found significant positive correlations between NT-proBNP and diastolic pulmonary pressure (r = 0.59; p = 0.005) and pulmonary capillary wedge pressure (PCWP) (r = 0.51; p = 0.015). Multiple linear regression analysis showed that the association between NT-proBNP and PCWP was not affected by creatinine level. CONCLUSION: NT-proBNP is a biomarker of left ventricular cardiac filling pressures in untreated pre-eclamptic patients.

Spontaneous pneumomediastinum: a rare presentation of diabetic ketoacidosis in a pregnant woman.

Pneumomediastinum (PM) or mediastinal emphysema is defined as the presence of free air around mediastinal structures. Spontaneous (or atraumatic) pneumomediastinum (SPM) is a rare complication during pregnancy. Primary or spontaneous PM can arise due to increased intra-alveolar pressure. Secondary PM is due to direct trauma, intrathoracic infections or violation of the aerodigestive track. This case report describes a pregnant woman newly diagnosed with diabetes presenting with an SPM due to vigorously vomiting and Kussmaul's breathing caused by diabetic ketoacidosis. Appropriate management of SPM and its underlying cause is required to reduce the risks for both mother and child.